Group benefits enrolment form
Instructions
• Section 1 is to be completed by the plan administrator.
• All remaining sections are to be completed by the plan member and returned to your plan administrator.
Please PRINT clearly. Complete the form in ink, sign and date the form on the last page and return to your plan administrator for handling.
1
Information to be completed by plan administrator
Contract number
Contract holder name
Date of hire/re-hire (yyyy-mm-dd)
New plan member
Plan member ID
Class/Plan
Re-hire
Effective date of coverage (yyyy-mm-dd)
Location/billing group number
Occupation
Salary
Location/billing group name
Basis
$
2
Annual
Monthly
Bi-weekly
Semi-monthly
Weekly
Hourly (Hrs./Wk.
Other
(please specify)
)
Plan member details
Plan member’s last name
Middle initial
First name
Gender
Male
Female
Address (street number and name)
Apartment or suite
City
Province
Date of birth (yyyy-mm-dd)
Language
English
Postal code
Email address
French
Province of residence
Marital status
3
Province of employment
Single
Married
Common Law
Divorced
Separated
Widowed
Telephone number
Civil Union
Coverage selection
Single
Family
Refusal of benefits
If you or your dependents are presently covered for Extended Health Care and/or Dental Care benefits under another group contract you
may refuse to be covered for such benefit(s) under this contract by selecting the applicable box for each benefit:
I refuse coverage for myself and my dependents under:
Extended Health Care
Dental Care
I refuse coverage for my dependents under:
Extended Health Care
Dental Care
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4
Banking details
If you wish to have your Extended Health Care and/or Dental Care benefit payments deposited directly into your bank account, attach a
void cheque, direct deposit form or bank verification statement.
If you do not have a chequing account, you must provide a direct deposit form or bank verification statement from your bank branch.
This form must be provided by your bank, trust company, caisse populaire or credit union in Canada, and be signed and stamped by a
banking representative. If your bank provides an online direct deposit form, pre-populated with your banking information, this can also be
submitted. These forms must contain your name, the Bank Number, your Branch Number and Account Number to facilitate your benefit
payment being deposited directly into your account.
Please attach a void cheque, direct deposit form or bank verification statement
5
Spouse details
IMPORTANT: A spouse must first claim from his/her own employer's plan.
Spouse’s last name
Spouse’s first name
Gender
Male
Date of birth (yyyy-mm-dd)
Female
Is your spouse covered for Extended Health Care and/or Dental Care benefits by his/her employer’s plan?
No
Yes
Extended Health Care
Dental Care
If yes, please indicate spouse’s coverage:
Family
Family
Single
Single
Name of benefits carrier:
6
Children details
IMPORTANT: Claims for covered children must be sent first to the plan of the parent whose birth date falls earlier in the year.
Student*
Over-age
disabled
child**
Male
Yes
Yes
Female
No
No
Male
Yes
Yes
Female
No
No
Male
Yes
Yes
Female
No
No
Male
Yes
Yes
Female
No
No
Gender
Child’s last name
Child’s last name
Child’s last name
Child’s last name
Child’s first name
Child’s first name
Child’s first name
Child’s first name
Date of birth (yyyy-mm-dd)
Date of birth (yyyy-mm-dd)
Date of birth (yyyy-mm-dd)
Date of birth (yyyy-mm-dd)
* A student is a child age 21 or over but under age 25, who is a full-time student attending an educational institution recognized by Canada
Revenue Agency, as long as the child is not married or in any other formal union and is dependent on you for financial support.
** To enrol an over-age disabled child, complete a Disabled Child Coverage form, and send it to us within 6 months of the date the
dependent reaches the age limit.
(For Quebec plan members, please check with your plan administrator for dependent student age limit.)
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7
Beneficiary nomination
IMPORTANT:
Be sure to show the beneficiary’s first and last name, as well as the relationship to you.
You must initial any changes or deletions. Correction fluid cannot be used.
A revocable nomination can be changed at any time without the beneficiary’s consent, however, you cannot change an irrevocable
beneficiary nomination unless certain requirements are met.
If you are nominating a beneficiary who is a minor, please see section entitled Nomination of trustee for minor beneficiary other than
Quebec residents.
NOTE: In Quebec, any amount payable to a minor beneficiary during his/her minority will be paid to the parent(s) or legal guardian on
his/her behalf.
If you do not nominate a beneficiary, the proceeds will be paid to your estate.
Beneficiary for Employee BASIC Life and Accidental Death Benefits (if applicable)
Last name
First name
Relationship to plan member
Percentage
Last name
First name
Relationship to plan member
Percentage
Last name
First name
Relationship to plan member
Percentage
%
%
%
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check
the revocable box.
Revocable beneficiary
8
Appointing contingent beneficiaries
If you wish to appoint a contingent beneficiary, in the event that there are no surviving beneficiaries at the time of your death, please
complete this section.
If there are no surviving beneficiaries at the time of my death, I declare that the following contingent beneficiaries shall receive the
proceeds. If there are no surviving contingent beneficiaries at the time of my death, the proceeds shall be paid to my estate.
Unless I specify otherwise, my contingent beneficiary will apply to all my benefits.
Last name
First name
Relationship to plan member
Percentage
%
Last name
First name
Relationship to plan member
Percentage
Last name
First name
Relationship to plan member
Percentage
%
%
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check
Revocable beneficiary
the revocable box.
9
Nomination of trustee for minor beneficiary other than Quebec residents
If you wish to designate minor children as beneficiaries, a trustee must be designated.
NOTE: In Quebec, any amount payable to a minor beneficiary during his/her minority will be paid to the parent(s) or legal guardian on
his/her behalf.
Any payments becoming due while the beneficiary(s) is a minor* are to be made to
as trustee, or failing such trustee to the
duly appointed guardian of such minor child as trustee. Payment to the trustee will discharge the company.
* A minor is a child who has not reached the age of majority as defined by provincial legislation.
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10 Authorization and signature
I am authorized to disclose information about my spouse and dependents in order to enrol them in the plan.
By enrolling in this plan, I authorize the following:
• Sun Life Assurance Company of Canada, its agents and service providers, its reinsurers and their service providers to
collect, use and disclose relevant information about me to underwrite, administer, adjudicate and deposit claim payments,
• My plan sponsor to use the information collected in this form for benefits administration and to make any necessary
payroll deductions which may be required,
• Sun Life Assurance Company of Canada and my plan sponsor to collect, use and disclose information about me, my spouse
and dependents necessary for enrolment and for the purposes of continuing administration of the plan.
I declare that the information above is accurate and true. Inaccurate information may invalidate a claim.
A photocopy or electronic version of this authorization is as valid as the original. A photocopy or electronic version of this
form is not valid for recording beneficiary nominations.
Plan member signature
Date (yyyy-mm-dd)
X
Respecting your privacy
Respecting your privacy is a priority for the Sun Life Financial group of companies. We keep in confidence personal information about you
and the products and services you have with us to provide you with investment, retirement and insurance products and services to help
you meet your lifetime financial objectives. To meet these objectives, we collect, use and disclose your personal information for purposes
that include: underwriting; administration; claims adjudication; protecting against fraud, errors or misrepresentations; meeting legal,
regulatory or contractual requirements; and we may tell you about other related products and services that we believe meet your
changing needs. The only people who have access to your personal information are our employees, distribution partners such as advisors,
and third-party service providers, along with our reinsurers. We will also provide access to anyone else you authorize. Sometimes, unless
we are otherwise prohibited, these people may be in countries outside Canada, so your personal information may be subject to the laws
of those countries. You can ask for the information in our files about you and, if necessary, ask us in writing to correct it. To find out more
about our privacy practices, visit www.sunlife.ca/privacy.
You have a choice
We will occasionally inform you of other financial products and services that we believe meet your changing needs. If you do not wish to
receive these offers, let us know by calling 1-877-SUN-LIFE (1-877-786-5433).
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